Nova Scotia Nominee Program

NSNP 100 Application Form for the Principal Applicant

Refer to the appropriate Nova Scotia Nominee Program Application Guide for the stream to which you are applying. Ensure
that all documents requested in the Application Guide are included with your application. Incomplete applications will
not be processed.

Section A Nova Scotia Nominee Program Stream

I am applying to the following stream of the Nova Scotia Nominee Program:
Skilled Worker
Nova Scotia Demand: Express Entry
Family Business Worker

Nova Scotia Experience: Express Entry

Section B Personal Information

Family name (exactly as on passport/travel document):
Given name (exactly as on passport/travel document):
Date of birth (dd/mm/year):
Country of birth:

Citizenship(s):

Principal applicants full name in native language:

Have you ever used any other name (e.g., maiden name, alias, nickname)?
If yes to the above question, provide the names:

Yes

No

Family name(s)
Given name(s)
Gender:

Male

Female

PASSPORT/TRAVEL DOCUMENT:
Do you have a valid passport/travel document?
Yes
No
Passport/Travel document number (exactly as shown on your passport or travel document):
Issuing Country:

NSNP 100 Application Form (May 12, 2015)

Expiry date (dd/mm/year):

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Current country of residence: ____________________________________________

If currently in Canada, what is your status?
Temporary Foreign Worker

Student

Visitor

Expiry date of your work permit, study permit or temporary resident visa
(dd/mm/year):
If your permit or visa has expired or is about to expire, when did you apply for a new one?
(dd/mm/year):

Not applicable

CONTACT INFORMATION (Your personal information, do not provide contact information for a representative, consultant, or lawyer):
Email address:
(By providing an email address, you authorize the NSNP to release information about you and your dependents to this
address.)
Telephone number(s):
________________________________________
Mobile (Country code) Number

________________________________________
Home (Country code) Number

________________________________________
Work (Country code) Number

Mailing Address
street address

province, state or district

city, town or village

country

postal code

Residential Address
Same as mailing address?
Yes
No
If no:
street address

province, state or district

NSNP 100 Application Form (May 12, 2015)

city, town or village

country

postal code

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RESIDENCES
Where do you intend to live in Nova Scotia (community, county)?

During the past 5 years have you lived in any country other than your country of citizenship or your current country of
residence for more than six months?
Yes
No
List all locations where you have lived in the past 5 years. Use additional pages, if necessary.
NOTE: Do not leave any gaps in time. Even a gap of one month will result in a delay in the processing of your application.
From mm/year

City or Town

Province, State or District

Country

To mm/year

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MARITAL STATUS
What is your current marital status?
Single

Married

Common-law

Legally separated

Divorced

Widowed

Other

If you are married or in a common-law relationship, provide the date (dd/mm/year) on which you were married or entered into
the common-law relationship: _____________________________
Have you previously been married or in a common-law relationship?
Yes

No

If yes, provide the following details of your previous spouse(s) or common-law partner(s):
Family name:
Given name:
Date of birth (dd/mm/year):
Type of Relationship:

Married

Common-law partner

Married

Common-law partner

From (dd/mm/year):
To (dd/mm/year):

Family name:
Given name:
Date of birth (dd/mm/year):
Type of Relationship:
From (dd/mm/year):
To (dd/mm/year):

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DETAILS OF FAMILY MEMBERS

You must provide the following details about each of your family members, whether they will accompany you to Nova Scotia or
not. Family members include your spouse or common-law partner, all of your dependent children and those of your spouse or
common-law partner who are not already permanent residents or citizens of Canada.
Spouse or Common-law
Partner

Family Member

Family Member

Family name (as on passport

or travel document):
Given name (as on passport or
travel document):
Date of birth (dd/mm/year)
Country of birth
Country of citizenship
Country of residence
Gender
Relationship to principal
applicant
Accompanying principal
applicant to Canada?

Yes

No

Yes

No

Yes

No

Passport/Travel Document
document number
Issuing country
Expiry date (dd/mm/year)
Highest level of education
Native language/Mother
tongue
Current occupation
Previous spouse or commonlaw partner

Yes

No

If yes, provide:

Family name
Given name
Date of birth (dd/mm/year)
Type of relationship
From (dd/mm/year)
To (dd/mm/year)

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DETAILS OF FAMILY MEMBERS (Continued)

You must provide the following details about each of your family members, whether they will accompany you to Nova Scotia or
not. Family members include your spouse or common-law partner, all of your dependent children and those of your spouse,
or common-law partner who are not already permanent residents or citizens of Canada.
Family Member

Family Member

Family Member

Family name (as on passport

or travel document):
Given name (as on passport
or travel document):
Date of birth (dd/mm/year)
Country of birth
Country of citizenship
Country of residence
Gender
Relationship to principal
applicant
Will accompany principal
applicant to Canada?

Yes

No

Yes

No

Yes

No

Passport/Travel Document
document number
Issuing country
Expiry date (dd/mm/year)
Highest level of education
Native language/Mother
tongue

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Section C General Information

Assistance in completing the application
Did you have help preparing your immigration forms?
If yes, who provided this assistance (Name the person)
Lawyer*:
Immigration consultant*:

Yes

No

Employer:
Other:

*Note: An authorized, paid immigration representative must be a member in good standing of either the Immigration Consultants of Canada
Regulatory Council (ICCRC), a Canadian provincial or territorial law society, or the Chambre des notaires du Qubec. For more information on
immigration representatives and who may represent you, visit www.cic.gc.ca/english/information/representative/rep-who.asp

How did you learn about the Nova Scotia Nominee Program?
Nova Scotia promotion material
Nova Scotia Office of Immigration Website
Visa Office

Immigration Agent
Friend
Employer

Immigration job fair or event overseas (specify place and date):

Other (specify):

Section D Application History

Federal Expression of Interest
Provide your Express Entry Profile Number if you have one: _________________________________
Provide your Express Entry Job Seeker Validation Code if you have one: _________________________________
Federal Application
Have you or a family member accompanying you, previously made application to Citizenship and Immigration Canada for
admission as an immigrant (permanent resident or refugee claimant)?
Yes
No
If yes, complete the following:
Applicants full name:

Family name, Given name

Citizenship and Immigration Canada file number:

Date of application (dd/mm/year):
Result (in-process, approved, refused, withdrawn):
Intended destination in Canada:

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Provincial Application
Have you or a family member accompanying you previously applied for provincial nomination or permanent residence under
any other provincial program?
Yes

No

If yes, complete the following:

Applicants full name:

Family name, Given name

Province or territory of application:

File number:

Date of application (dd/mm/year):

Result (in-process, approved, refused, withdrawn):

Section E Language
Native Language/Mother Tongue:
Which do you use most often, English or French?
English
French
Have you taken a Canadian English Language Proficiency Index Program (CELPIP) test, International English Language
Testing System (IELTS) test or Test d'valuation de franais (TEF) test to assess your ability in English or French?
Yes
No
Proof of language test must be attached for all Nova Scotia Demand: Express Entry applicants and for any applicant with a job
offer at the NOC C or NOC D skill level. (Results of their official English language proficiency test (CELPIP General or IELTS
General Training) OR their official French language proficiency test (TEF))
If your first language is not English or French, you need to demonstrate that you can communicate well in English or in French
in familiar social and work situations. Attach relevant documentation as per the application guide (e.g., language tests, primary
language of communication at work or at school).
Spouse or common-law partners language ability:
Which does your spouse or common-law partner use most often, English or French?
English
French
Has your spouse or common-law partner taken a CELPIP, IELTS or TEF test to assess ability in English or French?
Yes
No
If you are a Nova Scotia Demand: Express Entry applicant, and you are claiming adaptability points for your spouse or commonlaw partners language proficiency, you must include, with your application to Nova Scotia Office of Immigration, the results of
their official English language proficiency test (CELPIP General or IELTS General Training) OR their official French language
proficiency test (TEF).

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Section F Nova Scotia or Other Canadian Connections

Do you or your spouse or common-law partner have relatives (including, dependent children, mother, father, brothers, sisters,
aunts, uncles, cousins, grandparents, grandchildren, niece, nephew) living in Nova Scotia or elsewhere in Canada?
Yes

No

If yes, provide details below of all your relatives living in Canada. NOTE: If you are applying under the Nova Scotia Demand:
Express Entry stream, you must provide proof of relationship, proof of relatives status and proof of relatives residency.
(Adaptability points provided only for relatives 18 years or older on date of application who are Canadians or permanent
residents living in Nova Scotia.)

Applicant
Name of relative (family name, given name)

Relationship (e.g., sister)

Province/Territory

Are they a Canadian citizen or permanent resident?

Telephone Number

Years in Canada

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

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Spouse or common-law partner

Name of relative (family name, given name)

Relationship (e.g., sister)

Province/Territory

Are they a Canadian citizen or permanent resident?

Telephone Number

Years in Canada

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

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Have you or your spouse or common-law partner, or dependent children lived in or visited Nova Scotia or elsewhere in
Canada in the last 10 years?
Yes

No

If yes, describe each of the stays in Canada by you or your spouse, common-law partner or dependent children:
From: mm/year
To: mm/year

Who lived in or visited Canada?

Province(s)

Reason: work, visit, or study

Has your spouse or common-law partner worked in Nova Scotia?

Yes

No

From mm/year
To mm/year

If yes, provide the following details.

City of employment

Name of employer

Occupation

Section G Education
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Provide the number of years of school you successfully completed for each of the following levels of education:
Elementary/primary
Secondary/high school
University/college
Trade school or other post-secondary school
Give full details of all the secondary and post-secondary education (including university, college and apprenticeship training)
you have had:
From mm/year

Name of Institution

City and Country

Course, degree, certificate

To mm/year

Have you received a scholarship or award that requires you to return to your home country following the completion of your
degree?
Yes

No

If yes, have you satisfied the terms of this scholarship or award?

Yes

No

Has your spouse or common-law partner studied in a Nova Scotia secondary or post-secondary institution full time for two
years or more?
Yes

No

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Section H Employment
Do you have an offer of employment?
Yes
No

WITH OFFER OF EMPLOYMENT IN NOVA SCOTIA

Name of employer/company:
Address of employer/company:
street address

city, town or village

Postal code

Your position title:

National Occupational Classification (NOC) four-digit code1:
Offered salary:

WITHOUT OFFER OF EMPLOYMENT IN NOVA SCOTIA

If you are applying for a stream of the NSNP which does not require a job offer, what is your intended occupation?

National Occupational Classification (NOC) four-digit code1:

The National Occupational Classification four-digit code sorts occupations according to skill type and skill level. The digits
of the NOC code reflect important information about the occupation it represents (e.g., 3113 Dentists - 31 indicates that
this is a health occupation and it requires university level education). For further information, see your application guide
and/or refer to NOC resources online at Employment and Social Development Canada.
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Personal History
Provide the details of your personal history since the age of 18, or the past 5 years, whichever is most recent. Start with the
most recent information. Under Activity, write your occupation or job title if you were working. If you were not working,
provide information on what you were doing (for example: unemployed, studying, travelling, retired, in detention).
NOTE: Do not leave any gaps in time. Even a gap of one month will result in a delay in the processing of your application.
From mm/year

Activity

To mm/year

NSNP 100 Application Form (May 12, 2015)

City and Country

Name of company, employer, school, facility,

as applicable

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Section I Settlement
In your own words, tell us briefly about your plans to settle in Nova Scotia and your future here. Statements copied from someone
or somewhere else are not acceptable.

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Section J Financial Information

This section is not required for applicants to the Nova Scotia Experience: Express Entry stream.
You must present the most up-to-date financial documents to support all of the information provided in this section. Provide
information about all liquid assets and all liabilities for the Principal Applicant and spouse or common-law partner. You may be
asked to provide updated financial information prior to a decision being made on your application.
Indicate all exchange rates used:

1.00 ___________________ = _____________ CAD $

(identify your currency)

1 CAD $ = ________________________________
(Identify your currency)

Date of exchange rate ___________________________

A. Unencumbered Funds Available for Settlement
In order to successfully settle in Nova Scotia, you must have sufficient settlement supports and financial resources.
Considering the liquid assets and liabilities listed below, indicate the amount of unencumbered transferable and available
funds you have, in Canadian dollars, which will be available for your settlement needs.
$_______________
B. Liquid Assets
List all assets separately by institution, account number, and full name(s) associated with each account. Show value in Canadian
dollars and original currency. List only unencumbered funds, meaning readily transferable liquid assets such as cash in the
bank, guaranteed investment certificates or similar financial instruments that can be cashed easily. Do not include the value of
real estate or jewellery, furniture, vehicles and other personal assets. Use extra paper if necessary.
Description of assets (bank accounts, investments, pensions, etc.)

CAD $ Amount

Original Currency Amount

$
$
$
$
$
$
$
Total liquid assets (add all amounts above)

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C. Liabilities (all debts)

List all liabilities separately by institution, account number and full name(s) associated with each account. Show value in
Canadian dollars and original currency. Include mortgages (principal and interest owed), bank loans, personal loans, lines of
credit and credit card balances.
Description of liabilities (mortgages, loans, credit card balances,
etc.)

CAD $ Amount

Original Currency Amount

$
$
$
$
$
$
$
Total liabilities (add all amounts above)

Alimony and child support

Do you or your spouse or common-law partner have any financial or legal responsibility towards children from a previous
relationship?
Yes
No
If yes, complete the following and provide supporting documents:
Name of child (Family name, given names) and date of birth (dd/mm/year):
1.
Description of responsibility:
2.
Description of responsibility:
3.
Description of responsibility:

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Section K Documents Checklist

A detailed explanation of all the forms and supporting documents can be found in the Application Guide.
If copies are requested, do not send originals as they will not be returned to you. Review and organize your completed forms
and supporting documents in the order below before submitting your application. Where necessary, provide a short
description of what has been provided in the Brief Detail of Document Provided column. The Nova Scotia Office of
Immigration reserves the right to request further information if required.
In the chart below, the following abbreviations will be used.
PA: Principal applicant
Spouse: Spouse/Common-law partner
Dep: Dependent over 18
Add dep: Additional dependents. This is only applicable if you have more than 2 dependents. Indicate in the space provided x
___ how many additional dependents you have that apply to this item.
Nova Scotia Nominee Program forms provide ORIGINALS
Check or
indicate n/a

Document

Who must provide the document

1 passport-sized colour photograph (taken and datestamped within six months of application)

PA

NSNP 100 Application Form

PA

Dep #2

n/a

NSNP 200 (if applicable)

PA

n/a

NSNP 300 (if applicable)

PA

n/a

NSNP 50 Use of a Representative (if applicable)

PA

Spouse

Dep #1

Add dep x ___

Spouse

Dep #1 (18 or older)

Dep #2 (18 or older)
Add dep x ___ (18 or older)
/

n/a

NSNP 60 Authority to Release Personal Information to

a Designated Individual (if applicable)

PA

Spouse

Dep #1 (18 or older)

Dep #2 (18 or older)
Add dep x ___ (18 or older)

Citizenship and Immigration Canada forms provide COPIES ONLY

Forms IMM 5604 and IMM 5409 are available at www.cic.gc.ca/english/immigrate/provincial/apply-application.asp
/

n/a

Separation Declaration for Minors Travelling to Canada

(if applicable) [IMM 5604]

n/a

Statutory Declaration of Common-law Union (if

applicable) [IMM 5409] Must be signed by commissioner
of oaths

NSNP 100 Application Form (May 12, 2015)

For the non-accompanying parent/guardian,

former spouse or former common-law
partner and witnessed by a notary public
PA

Spouse

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Supporting Documents provide COPIES ONLY

Check or
indicate n/a

Document
Valid passports / travel
documents

Who must provide the

document
PA

Brief Detail of Document Provided

Spouse

Dep #1
Dep #2
Add dep x ___

n/a

Proof of legal status in your

country of residence if other than
your country of nationality (e.g.,
work permit)

PA

Birth certificates identifying both

parents

PA

Spouse

Dep #1
Dep #2
Add dep x ___
Spouse

Dep #1
Dep #2
Add dep x ___

n/a

Marriage certificate (if applicable)

PA

Spouse

Dep #1
Dep #2
Add dep x ___
/

n/a

Divorce and/or annulment

certificate (if applicable)

PA

Spouse

Dep #1
Dep #2
Add dep x ___

n/a

Custody maintenance documents

and permission for the child to
come to Canada (if applicable)

PA

Spouse

Dep #1
Dep #2
Add dep x ___

n/a

Adoption papers (if applicable)

PA

Spouse

Dep #1
Dep #2
Add dep x ___
/

n/a

Death certificate for former

spouse (if applicable)

PA

Spouse

Dep #1
Dep #2
Add dep x ___

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Supporting Documents provide COPIES ONLY

Check or
indicate n/a
/

n/a

Document
Correspondence on previous
immigration applications to
Canada (if applicable)

Who must provide the

document
PA

Brief Detail of Document Provided

Spouse

Dep #1
Dep #2
Add dep x ___

Education certifications received

(e.g., degrees, diplomas or
certificates)

PA

Spouse

n/a

For Nova Scotia Demand Express

Entry, an Educational Credential
Assessment (ECA), from CICs
designated agencies for foreign
credentials

PA

n/a

Proof of English or French

language ability (Spouse, only if
applicable for Nova Scotia
Demand Express Entry)

PA

Spouse

Supporting employment history

and documents (Spouse, only if
applicable for Nova Scotia
Demand Express Entry)

PA

Spouse

n/a

For Nova Scotia Demand Express

Entry, documentation to show
work experience match with NOC
2011

PA

n/a

Certification with licensing bodies,

regulatory agencies (if applicable)

PA

Resume / Curriculum Vitae

PA

Financial information (Applies to

all streams except NS
Experience: Express Entry.)
proof of settlement supports and
transferable funds (e.g., bank
statements, investment portfolio)

PA

n/a

NSNP 100 Application Form (May 12, 2015)

Spouse

Dep #1
Dep #2
Add dep x ___

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Supporting Documents provide COPIES ONLY

Check or
indicate n/a
/

n/a

Document
For Nova Scotia Demand Express
Entry adaptability points, proof of
residency, proof of status and
proof of relationship for close
relatives living in N.S. (if
applicable)

Who must provide the

document
PA

Brief Detail of Document Provided

Spouse

Supporting Documents Related to the Employer provide COPIES ONLY

Check or
indicate n/a

Document

Who must provide

the document

n/a

Employment Offer

PA

n/a

Job Description

PA

n/a

Labour Market Impact

Assessment (LMIA)

PA

n/a

Recruitment Activities

PA

NSNP 100 Application Form (May 12, 2015)

Brief Detail of Document Provided

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Section L Authority to Collect and Disclose Information

Initial beside each statement and authorization to acknowledge agreement and then sign at the bottom of the page.
Initials

____ ____ This information release must be signed by the principal applicant, spouse, common-law partner and all
accompanying dependent family members 18 years or older, authorizing the Government of Nova Scotia to
collect, use, retain, disclose, and destroy personal information to assess your application to the Nova Scotia
Nominee Program and to research, monitor, and evaluate the Program under the authority of the Nova Scotia
Freedom of Information and Protection of Privacy Act and other relevant provincial legislation, the Immigration
and Refugee Protection Act and Regulations and other relevant Government of Canada legislation. If you have
any questions about the collection of personal information, contact the Nova Scotia Office of Immigration.
____ ____ I authorize immigration officials with the Government of Nova Scotia to disclose personal information to the
Government of Canada, and to collect personal information from the Government of Canada, as necessary for
the Nova Scotia Nominee Program and my federal immigration application for the purpose of assessing my
application, verifying information in this application, and evaluating the Nova Scotia Nominee Program, or in the
event of any suspected non-compliance with any provincial or federal law.
____ ____ I authorize the Government of Nova Scotia to disclose and collect personal information to and from government
departments in Nova Scotia to assess this application, or in the event of any suspected non-compliance with
any provincial or federal law.
____ ____ I understand that the Government of Nova Scotia may contact any person to verify information provided by me
in this application. I understand that I have the right to examine and request corrections or amendments to my
personal information, whether held by a provincial or federal government office.
____ ____ I consent to the Government of Nova Scotia collecting any personal and other information, including information
about my address(es), telephone number(s), social insurance numbers, marital status, employment, income,
assets, liabilities, benefits received under other provincial and federal government programs or any other
relevant personal information, required as part of my involvement in the Nova Scotia Nominee Program and to
locate and contact me about evaluating the program and my participation in it.
____ ____ I consent to the Government of Nova Scotia collecting this information from any federal, provincial, municipal or
other local authority or any other person, department, agency or organization holding such information.

Signature of principal applicant

Date (dd/mm/year)

Signature of spouse or common-law partner

Date (dd/mm/year)

_______________________________________________
Signature of dependent family member 18 years or older

NSNP 100 Application Form (May 12, 2015)

Date (dd/mm/year)

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Section M Declaration
Applicant and spouse or common-law partner and all accompanying dependent family members 18 years or older must initial
beside each statement and authorization to acknowledge agreement and then sign at the bottom of the page.
Initials

____ ____

I declare that the information I have given in this application is truthful, complete and correct.

____ ____

I understand that any false statement or concealment of information may result in Citizenship and Immigration
Canada and/or the Nova Scotia Office of Immigration (NSOI) refusing my application or, if applicable
withdrawing my nomination and/or my Canadian permanent residence visa.

____ ____

I understand that my failure to provide a complete application package including all required forms and
credible, supporting documentation will result in my application not being processed.

____ ____

I intend to settle in the Province of Nova Scotia upon arrival in Canada.

____ ____

I declare that I agree to provide NSOI with my contact information (current address, phone number(s), email)
within 30 days of arriving in Canada and to inform NSOI of any change of address or phone number(s) or
email for a period of 3 years after arriving in Canada.

____ ____

I understand that NSOI is not obligated to assess/process any applications submitted. Applications to NSOI
are treated as an expression of interest, and as such, will be processed according to quality of the application
(completeness, eligibility), labour market information, occupational supply and demand forecasting,
application volumes, and any other factors at NSOIs discretion. By submitting an application to NSOI, I
acknowledge and agree that my application may not be processed in the order received, or at all. Further the
decision to assess/process any particular application, and the outcome of any such assessment/processing,
is at NSOIs sole discretion. Program criteria are eligibility minimums, and meeting program criteria does not
guarantee that my application will be assessed, processed, or granted.

____ ____

I understand all the statements for the authority to collect and disclose personal information and this
declaration, and have asked for and received an explanation on every point that was not clear to me.

_______________________________________________

_____________________________________________

_______________________________________________

_____________________________________________

_______________________________________________

_____________________________________________

Signature of principal applicant

Signature of spouse or common-law partner

Signature of dependent family member 18 years or older

NSNP 100 Application Form (May 12, 2015)

Date (dd/mm/year)

Date (dd/mm/year)

Date (dd/mm/year)

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Submit completed form or application to the address provided below:

Nova Scotia Office of Immigration
1741 Brunswick St., Suite 110A
P.O. Box 1535
Halifax, Nova Scotia
CANADA B3J 2Y3
Tel: (902) 424-5230
Fax: (902) 424-7936
Email: nsnp@novascotia.ca
Web: www.novascotiaimmigration.ca

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